head to toe assessement

8/10/2019 Head to Toe Assessement

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HEALTH

ASSESSMENT

HEAD TO TOE PHYSICAL

EXAMINATION


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HEALTH ASSESSMENT

DEFINITION:

Health assessment or clinical examination (more

popularly known as a check-up) is the process by

which a doctor investigates the body of a patient for

signs of disease.


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HEALTH

HISTORY

PHYSICAL

ASSESSMENT


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HEALTH HISTORY

A health history is the collection of subjective datathat provides a detailed profile of the patient health

status. Therapeutic communication skill and interview

technique used to gather health history.

It helps to identify actual and potential healthproblem.


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Physical examination is an integral part of healthexamination and it includes head to toe examinationof the patient to rule out any deviation from the

normal.

PHYSICAL EXAMINATION


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PURPOSETo gather baseline data.

To confirm the alterations, disease or inability toperform the activities of daily living.

To supplement data obtained in the nursing history.

To make nursing diagnosis.To make clinical judgments about the clientschanging health status and management.

To evaluate the effectiveness of health care.

.


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PREPARATIONS

Comfort

Position,gowning

Height of

examinationtable

Lightsources

Eliminatedistractions

Equipments:clean & inworking

condition
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INSTRUMENTSSUPPLIES PURPOSE

Flash light or

penlight

To assist viewing of the pharynx and

cervix or to determine the reactions

of the pupils of the eye

Nasal speculum to visualization of the lower and

middle turbinates

Opthalmoscope To visualize the interior of the eye

Otoscope To visualized the ear drum and

external auditory canal

Knee hammer To test reflex
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INSTRUMENTSSUPPLIES PURPOSE

Tuning fork To test hearing acuity and vibratory sense.

Vaginal speculum To assess cervix and vagina

Cotton applicator To obtain specimens

Gloves To prevent contamination

Lubricant To ease insertion of instruments

Tongue depressors To depress the tongue

Stethoscope To auscultate heart, lung, abdomen and

cardiovascular sound.

Thermometer To check the temperature
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POSITIONS OF PATIENT

2. PRONE POSITION:

1. SUPINE POSITION:


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3. SITTING POSITION:

4. SEMI FOWLERs POSITION:


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5. SIMs POSITION:

6. KNEE-CHEST POSITION:


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7. DORSAL RECUMBENT POSITION:

8. LITHOTOMY POSITION:


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9. TRENDELENBERGs POSITION:


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METHODS OF EXAMINING:

1. Inspection:

A method of systematic observation. Inspectionshould begin with general observation of the patientprogressing to specific body areas.


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2. Palpation:Process of examining patients by application of thehands.

Used to determine:

Consistency of tissue.

Alignment and intactness

of structures.

Symmetry of body parts.

Areas of warmth and

tenderness.


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Parts of hands used for variouspalpation:

Part of hand Type of palpation

Finger tips To assess texture, shape,size, consistency andpalpation

Dorsum of hand andfingers

To assess temperature

Palm of hand To assess vibration

Pinching of fingers To assess turgor,consistency and position


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For light palpation, press the skin gently with the tips oftwo or three fingers held close together.


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3. Percussion:Tapping of the body lightly but sharply to determineconsistency of tissues and/or organs through

vibration `& areas of tenderness.


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PERCUSSION

The sounds may be:

Resonance: a low pitched and loud soundheard over the normal lung tissues.

Hyper resonance: very loud , very lowpitched sound longer than resonancesignifies emphysema.

Tympany :a drum like sound heard overthe air filled tissues such as gastric air

bubble. Dull: A medium pitched sound with amedium duration without resonanceheard over solid tissues such as heart ,

liver.


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Percussion sound with examples:

Percussion

sounds

Intensity Pitch Percussion

example

Dullness Medium Moderate Liver

Resonance Loud Low Normal lung

Hyperresonance

Very loud Lower Emphysematouslung

Tympany Loud Higher Puffed out cheek, gastric airbubble


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4.Auscultation:Process of listening for sounds over body cavities todetermine presence and quality of heart, lung, andbowel sounds.


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TYPES OF AUSCULTATION

Direct auscultation: use of

unaided ear

Indirect auscultation:use ofstethoscope


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PROCESS OF HEALTH

ASSESSMENT:

I. GENERAL APPEARANCE BEHAVIOR:

i) Gender and race:Certain illnesses are more likely toaffect the specific gender and race. Eg. Risk of havingskin cancer is 20% higher in whites than in blacks.


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ii) Age: Age influences the normal physicalcharacteristics.

iii) Signs of distress: There may be obvious signs andsymptoms indicating pain, difficulty in breathing oranxiety.


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iv) Body type: Trim, muscular, obese or excessively thin.


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v) Posture: Observe whether the client has a slumped,erect or bent posture.


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vi) Gait: Observe the walking pattern of the client. Notwhether the movements are coordinated oruncoordinated.


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vii) Body movements: Note for any tremors involving theextremities.

viii) Hygiene and grooming: Note the appearance of hair,skin and finger nails. Also observe for the clothing.

ix)

Affect and mood:Affect is a persons feelings as they

appear to others.

x) Speech: An abnormal pace may be caused by emotions

and neurological impairments.xi) Substance abuse: Check for the history of substance

abuse.


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VITAL SIGNS:

Equipment Needed:

A Stethoscope A Blood Pressure Cuff

A Watch Displaying Seconds

A Thermometer


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1. Temperature:Temperature can be measured is several different ways:

Oral

Axillary

Aural

Rectal.

2. Respiration:

In adults, normal resting

respiratory rate is between

16-24 breaths/minute.


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3. Pulse:

A normal adult heart rate is between 60 and 100beats per minute. A pulse greater than 100beats/minute is defined to be tachycardia. Pulse lessthan 60 beats/minute is defined to be bradycardia.

4. Blood Pressure:

Record the blood pressure as

systolic over diastolic

(Eg. "120/70" ).


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HEIGHT, WEIGHT AND

CIRCUMFERENCE:

A persons general level of health can be reflected in

the ratio of height to weight. Weight is a routine measure during health visits.

A clients weight will normally vary daily because of

fluid loss or retention. Progressive weight gain is

` expected during pregnancy.

Head, chest and abdominalcircumference should be

assessed in case of infants.


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PHYSICAL EXAMINATION:


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Look

(Inspection)

Listen

(auscultation)

Feel

(palpation)

Tap(percussion)

Smell(olfaction)

SKILLS OF PHYSICAL EXAMINATION


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Cynosis

Erythema


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NORMAL NAIL SHAPE

Technique: view the index finger note the angle of

the nail base it should be above 160 degree.


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ABNORMAL NAIL SHAPES

Early clubbing

Late clubbing

B


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B. HEAD:

a. Eyes:Examine the conjunctiva,

sclera. Test pupils for irregularity,accommodation, and reaction.

Evaluate visual fields and visual

acuity.


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Vision

Visual activity(ability to see small

detail): by snellens chart.

Peripheral vision:


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b.

Ears:Examine the pinna and peri-auricular tissues. Testauditory acuity, perform Weber and Rinne tests.


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EARS

Examination of ears: Pull the ears backward andupward.

Instrument used: Auto scope

External ears:Crusts, discharges, lesions etc.

Tympanic membrane: Normally it is shiny, translucent,with a pearl grey color. See for any perforation,lesions, bulging.

Hearing:There are 3 ways for testing the hearing.


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Weber's test

It is used to assess the conductive

hearing loss.

Technique:Place a vibrating tuningfork in the midline of the persons

skull and ask if he can hear thesounds same in both the ears orbetter in one ear.

Result :

The person should hear the toneproduced by bone conductionequally in both ears, is the positivetest result


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Rinne test

This is a test to compare the air conduction and thebone conduction sounds.Technique:

Place the stem of the vibrating tuning fork onpersons mastoid process and ask him or her to signalwhen the sound disappears note the time in

seconds. Invert the tuning fork so the vibrating end isnear the ear canal he should hear the sound.Note the time in seconds.Results : AC : BC = 2 : 1


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c. Nose:Connect the nasal speculum to the otoscope and examine the nares,

noting the condition of the mucosa, septum and turbinate's.

d. Mouth:Examine the oral mucosa, the

tongue and teeth. Evaluate thefunction of cranial nerves IX, X,

and XII.

e. Face:Evaluation of symmetry, smile, frown, and jaw movement will provide

information about motor divisions of cranial nerves V and VII.


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C.Neck:

Palpate the neck with emphasis on the salivary glands,lymph nodes, and thyroid. Look for tracheal deviation.Identify the carotid arteries and auscultate for bruits.

LYMPH NODES


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Lymph nodes are assessed by palpating with the pad of the

finger for enlargement , tenderness and mobility . Normally nodes are not palpable. If palpable they should

be small, mobile, smooth and non tender.


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Thyroid: palpation for size , symmetry ,tenderness and nodules.


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Trachea: Palpation for alignment and position:

unequal space between trachea and sterno-cleidomastoid muscle on each side is abnormal, indicativeof trachea displacement.


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CAROTID ARTERY :

Palpate one carotid

artery at a time justbelow the upperborder of the thyroid

cartilage.

RESPIRATORY ASSESSMENT


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RESPIRATORY ASSESSMENT:


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http://en.wikipedia.org/wiki/File:Ben_Fraser_pectus_carinatum.jpg


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Funnel chest (Pectus excavatum

describes an abnormal formationof the rib cage that gives the chest

a caved-in or sunken appearance.)

Pigeon chest (Pectus carinatum, isa deformity of the chestcharacterized by a protrusion

of the sternum and ribs.)

D
http://en.wikipedia.org/wiki/File:Ben_Fraser_pectus_carinatum.jpg


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D.CHEST AND LUNGS:

i) Inspection:

Observe the rate, rhythm, depth, and effort of breathing.

Listen for abnormal sounds such as wheezes.

Observe for retractions.

ii) Palpation:

Identify any areas of tenderness.

Assess expansion and symmetryof the chest.

Check for tactile fremitus.


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iii) Percussion:

Percuss from side to side and top to bottom .

Categorize what you hear as normal, dull, or hyperresonant.

INTERPRETATION:Percussion Notes and Their Meaning:Flat or Dull Pleural Effusion or Lobar

Pneumonia

Normal Healthy Lung or Bronchitis

Hyper resonant Emphysema or Pneumothorax


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iv) Auscultation:

Use the diaphragm of the stethoscope to auscultatebreath sounds. Note the location and quality of thesounds you hear.

A f A l i

:


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Areas of Auscultation


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ABNORMAL BREATH SOUNDS :

Crepts : fine, short interrupted sound heard duringinspiration and expiration. Example : Respiratory distress.

Rhonchi : low pitched continuous musical sound heard

during expiration and clears with coughing. Example :Pneumonia.

Wheeze : high pitched continuous musical sound heardduring inspiration or expiration and does not clear with

coughing. Example : Pneumonia .

Pleural friction Rub : grating type of sound heard duringinspiration and does not clear with coughing, example :

Empyema .


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CARDIAC ASSESSMENT:

Inspection of the HeartThe chest wall and epigastrium is

inspected while the client is insupine position. Observe forpulsation and heaves or lifts.

Normal Findings:

There should be no lift or heaves.


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PALPATION OF THE HEART

The entire pre-cordium (anterior surface of the body covering

the heart and lower thorax) is palpated methodically using thepalms and the fingers, beginning at the apex, moving to theleft sternal border , and then to the base of the heart.

NORMAL FINDINGS:

No, palpable pulsation over the

aortic, pulmonary, and mitral valves.

Apical pulsation can be felt on

palpation.

There should be no noted abnormal

heaves, and thrills felt over the apex.

Percussion of the Heart Th h i f i i f


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The technique of percussion is oflimited value in cardiac assessment. It

can be used to determine borders ofcardiac dullness.

Auscultation of the Heart

Aortic valveRight 2ndintercostal

space (ICS) sternal border. Pulmonary ValveLeft 2ndICS sternal

border.

Mitral ValveLeft 5

th

ICSmidclavicular line.

Tricuspid Valve Left 5thICS sternalborder


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AV Valves- Tricuspid and Mitral Semilunar valves- Pulmonicand aortic


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Auscultating the heart

Auscultate the heart in all anatomic areas aortic, pulmonic, tricuspid andmitral.

Listen for the S1 and S2 sounds (S1 closure of AV valves; S2 closure ofsemi-lunar valve).

Listen for abnormal heart sounds e.g. S3, S4, and Murmurs.

Count heart rate at the apical pulse for one full minute.

Normal Findings:

S1 & S2 can be heard at all anatomic site.

No abnormal heart sounds is heard (e.g. Murmurs, S3 &S4).

Cardiac rate ranges from 60100 beats per min.


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ABDOMINAL ASSESSMENT

E


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E. ABDOMINAL ASSESSMENT:

Abdomen is divided into 4 main quadrants:

Right Upper Quadrant (RUQ) Right Lower Quadrant (RLQ)

Left Upper Quadrant (LUQ)

Left Lower Quadrant (LLQ)


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i) Inspection:

Look for scars, striae, hernias, vascular changes, lesions, orrashes, movement associated with peristalsis or pulsations.

Note the abdominal contour. Is it flat, scaphoid, or

protuberant?ii) Auscultation:

Place the diaphragm lightly on the

abdomen, listen for bowel sounds. Listen for bruits over the renal

arteries, iliac arteries, and aorta.


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iii) Percussion:

Percuss in all four quadrants using proper technique.

Categorize what you hear as tympanitic or dull.Tympany is normally present over most of theabdomen in the supine position. Unusual dullnessmay be a clue to an underlying abdominal mass.


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Liver Span

Percuss downward from the chest in the right mid-clavicular line until you detect the top edge of liverdullness.

Percuss upward from the abdomen

in the same line until you detect the

bottom edge of liver dullness.

Measure the liver span between these

two points. This measurement should

be 6-12 cm in a normal adult.


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vi) Palpation:

Palpation of the Liver

a Standard Method:

Place your fingers just below the

right costal margin and press firmly.

Ask the patient to take a deep breath.

You may feel the edge of the liver press against your

fingers. Or it may slide under your hand as the patientexhales. A normal liver is nottender.


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b

Alternate Method:

This method is useful when the patient is obese orwhen the examiner is small compared to the patient.

Stand by the patient's chest.

"Hook" your fingers just below

the costal margin and press

firmly.

Ask the patient to take a deep breath.

You may feel the edge of the liver press against yourfingers.


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GENITALIA AND RECTUM:Providing privacy

Not prolonging the examination

Warming instruments i.e. vaginal speculum

Using lubricants to minimize discomfort

Wear gloves during genital & rectal examination

Empty the bladder before examination


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Male genitals Inspect the skin of glance penis. Observe for any

lesions, color, discharge or inflammation.

Assess secondary sex characteristics , observe the

penis and testes for size and shape, color, texture ofscrotal skin symmetry and the distribution of pubichair , position of meatus and circumcision.

Palpate the penis using your thumb and first two

fingers. Note any tenderness or nodules. Normally,testes feel firm and not hard with similarconsistency.

Female genitalia


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Female genitalia

Female genitalia is examined by inspection andpalpation.

Inspect the external genitalia. Separate the labia and

inspect the labia minora, clitoris, urethral orifice andvaginal opening.

Observe for inflammation, discharge, ulceration,varicose veins, swelling and nodules.

In internal inspection, observe cervix for color,position, bleeding.


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EXTREMITIES:

Upper and lower Extremities are assessed for size and

symmetry , various patterns , colour and texture ofskin and nail beds , hair distribution on hands , lowerlegs , feet and toes . Observe for pigmentation , rashes, scars , ulcers and edema.


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HOMANS SIGN

Test for homans sign, an indicator of phlebitis in which

pain and soreness are present in the calf area when thefoot is dorsiflexed . The persons dorsiflexed leg issupported from calf with your non dominant hand . Noteany pain or soreness in the calf area. If present this would

be a positive homans sign ,indicating the possibility ofphlebitis .

MOTOR SYSTEM:


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MOTOR SYSTEM:

Inspect the voluntary muscles for atrophy,fasciculation (uncontrollable twitching)andinvoluntary movements. In addition assess gait ,

Romberg's sign for muscle strength andcoordination.

Gait: is a persons style of walking. To assess gait,instruct the person to walk across the room, turn and

walk back towards you . Observe the persons balanceand posture . Ataxia is an uncoordinated gait thatresult from cerebellar disease or intoxication.


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Rombergs test : Rombergs test is a test of sensory equilibrium.Instruct the person to stand with the feet together and eyesopen . Note the persons balance . Then have the person closethe eyes. Normally you will observe only minimal swaying . Apositive test will suggest cerebellar ataxia.


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REFLEXES OF MUSCLES:

Tests of muscle strength andassessment of common reflexes

Type Procedure Normal

reflex


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Deep

tendon

reflexes

Biceps Flex the clients arm at elbow withpalms down. Place your thumb inantecubital fossa at the base ofbiceps tendon . Strike the thumbwith the reflex hammer .

Flexion ofarm atelbow.

Triceps Flex the clients elbow , holding armacross the chest , or hold the upperarm horizontally and allow thelower arm to go limp. Strike tricepstendon just above the elbow .

Extensionat elbow.

Patellar Make the client sit with legs hangingfreely over the side of the bed orchair or have the client lie supineand support knee in a flexed

position . Briskly tap patellar tendon

Extensionof lower legat knee.

Procedures Normal

reflex
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Achilles Make the client assume the same

position as for patellar reflex. Slightlydorsiflex the clients ankle by graspingtoes in the palm of your hand . Strikeachilles tendon just above the heel.

Plantar

flexion offoot .

Babinskis

Have the client lie supine with legsstraight and feet relaxed . Take thehandle end of the reflex hammer andstroke lateral aspect of the sole fromthe heel to the ball of the foot , curvingacross the ball of the foot toward thebig toe.

Bending oftoedownwards.

Maneuvers to assess muscle strength:
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Muscle group Maneuver

Neck Place your hand firmly against the clients upper jaw .ask the

client to turn head laterally against resistance.

Shoulder Place your hand over the midline of the clients shoulder ,exerting firm pressure . Have the client raise shoulder againstresistance.

Elbow,Biceps,Triceps.

Pull down the forearm as the client attempts to flex the arm. Asthe clients arm is flexed ,apply pressure against the forearm

.ask the client to straighten his/her arm.

Hip ,Quadriceps

When the client is sitting apply downward pressure to thigh .Ask the client to raise his leg up from the table.The client sits, holding shin of the flexed leg . Ask him tostraighten his leg against the resistance.

MUSCLE STRENGTH


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To grade or quantify muscle strength, assess the patient asfollow:

Grade

Description

0/5 No muscle movement

1/5 Visible muscle movement, but no movement at the joint

2/5 Movement at the joint, but not against gravity

3/5 Movement against gravity, but not against added resistance

4/5 Movement against resistance, but less than normal

5/5 Normal strength

SENSORY SYSTEM:


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Light touch/ superficial pain: Using a wisp of cottonand a safety pin alternatively , touch the distal andproximal portions of the upper and lowerextremities.

The temperature test can be done by asking thepatient to touch and identify the hot and cold testtube filled with hot and cold water respectively.

Vibrationis assessed by tapping a tuning fork and

placing it firmly on a persons inter-phallengial jointof the finger and great toe. Ask the patient todescribe the sensation and to identify when thesensation ends.


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Two point discrimination: When assessing two pointdiscrimination , touch the person alternatively withone or two safety pins on a particular body part,

such as the finger pads . ask the patient if one or twosensations are felt.

Point localizationis assessed by touching variousparts of the persons body with a wisp of cotton. The

person is instructed to open the eyes after having feltthe touch and point to the area.


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CONSCIOUSNESS

Assessment of consciousness begins with notingwhether the client is awake and alert . If the person

has altered the level of consciousness , assess whetherthe person is demonstrating stupor or coma . Glasgowcoma scale to be maintained for the patient withaltered sensorium and in that three points are

observed: eye open response, verbal response andmotor response .

AFTER CARE:


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When the physical examination is over, remove thedrape & help the person to put on cloths. Be sure thepatient is safe and comfortable.

DISMANTLING OF ARTICLES:

Articles should be sent for sterilization. Disposablearticles should be immediately disposed off andreplacement of all the articles should be done to thearea specified.

POINTS TO BE REMEMBER:


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Ensure that adequate privacy is provided during theobservation.

Always take help in case of pediatric /unconsciouspatient / uncooperative patient .

Ensure adequate light.

Inform the patient / relatives before

and after the physical examination .

Record all the observations and

preserve in safe custody . Inform any abnormal findings

to senior nurse/doctor.


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head to toe assessement

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